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Which of the following findings would the nurse expect to observe in a client with peripheral arterial disease (PAD)? Select all that apply.
- A. Decreased peripheral pulses
- B. Pain with ambulation
- C. Reddish-brown ankle discoloration
- D. Bilateral dependent edema
- E. Protruding veins in the leg
Correct Answer: A,B,C
Rationale: Decreased pulses result from arterial obstruction. Pain with ambulation (claudication) is a hallmark of PAD. C: Correct - Reddish-brown discoloration indicates chronic arterial insufficiency. D: Incorrect - Edema is more typical of venous issues. E: Incorrect - Protruding veins suggest venous disease, not arterial.
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The nurse reviews the client's continuous telemetry monitor and observes the following. As the nurse reviews the client's current medications, which prescribed medication is most likely causing this tracing? See the image below.
- A. losartan
- B. nitroglycerin transdermal patch
- C. enalapril
- D. verapamil
Correct Answer: D
Rationale: Verapamil, a calcium channel blocker, can cause bradycardia or heart block, potentially leading to abnormal ECG tracings.
The following scenario applies to the next 6 items
The client is a 72-year-old male who presents to the emergency department with increasing
shortness of breath over the past two days that gets worse when he is lying flat in bed at night.
Item 1 of 6
History And Physical Nurses' Notes Flow Sheet
0700: The client is a 72-year-old male who presents to the emergency department with increasing shortness of breath over the past two days that gets worse when he is lying flat in bed at night. He states, "I feel like I can't catch my breath," and he had to sleep in a recliner. He reports a 4 lb weight gain over the last week and increasing fatigue. The client is alert and oriented but is using his accessory muscles to breathe. He reports feeling short of breath, orthopnea, and paroxysmal nocturnal dyspnea. He has bilateral pedal edema (+2), bilateral crackles heard upon auscultation, and jugular vein distention noted on his assessment. The
the client has a medical history of hypertension, coronary artery disease, and a prior myocardial infarction. He was diagnosed with heart failure with reduced ejection fraction (HFrEF) two years ago. Current home medications include lisinopril, metoprolol succinate, furosemide, and atorvastatin.
For each medication, choose the most likely option for drug classification and mechanism of action for heart failure: Spironolactone, Sacubitril/Valsartan, Dapagliflozin
- A. Spironolactone: MRA, Blocks aldosterone effects
- B. Sacubitril/Valsartan: ARNI, Blocks RAAS and neprilysin
- C. Dapagliflozin: SGLT2 inhibitor, Causes osmotic diuresis
Correct Answer: A,B,C
Rationale: Spironolactone: MRA (Mineralocorticoid Receptor Antagonist) blocks aldosterone, reducing fluid retention. Sacubitril/Valsartan: ARNI blocks RAAS and neprilysin, improving vasodilation and diuresis. Dapagliflozin: SGLT2 inhibitor causes osmotic diuresis, reducing fluid overload.
The nurse is preparing a client for a scheduled percutaneous coronary intervention (PCI). Which statement made by the client should be reported to the primary healthcare provider (PHCP)
- A. I took my metformin this morning.
- B. I get anxious when I am in closed spaces.
- C. I am allergic to shellfish.
- D. I may feel a warm sensation during the procedure.
Correct Answer: C
Rationale: Shellfish allergy may indicate iodine sensitivity, relevant for contrast dye used in PCI, requiring PHCP notification.
The nurse is assisting a physician in performing a bronchoscopy. The nurse suspects the client is experiencing a vasovagal response as evidence by the client's
- A. hypertension.
- B. bronchodilation.
- C. increase in heart rate (HR).
- D. decrease in heart rate (HR).
Correct Answer: D
Rationale: A vasovagal response causes bradycardia due to vagal nerve stimulation during procedures like bronchoscopy.
The nurse is performing an assessment on a client with congestive heart failure demonstrating ineffective coping. The nurse should plan to
- A. recommend a support group.
- B. review dietary items low in sodium.
- C. review the client's vaccination status.
- D. recommend the client take St. John's Wort.
Correct Answer: A
Rationale: A support group addresses ineffective coping by providing emotional support and coping strategies.